Rockefeller, Hazel NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hazel Mae Rockefeller Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/ /20'2 74 years War or Dates
Place o [Seats Hospital, Institution or
ii City, To V. •- Street Address
X %c.� X Glens F Glens II�SS 1H-{o- ital
Manner o eat r Natural Cause Accident ❑Homicide ❑Suicide L Undef'ermined Pending
Circumstances Investigation
Ili Medical Certifier Name Title
f
Add eobcrt W. Sponzo M. D.
ss
102 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, Tov ikrxV a3X Glens Falls Cemetery orCrematory397
❑Burial
> ' ❑Entombment 08/30/2012 Pine View Crematorium
Address
VCremation rY
� Qiieensbu NY 1_2804
Date Place Removed
Removal and/or Held
and/or Address
t Hold
0
Date Point of
❑Transportation Shipment
a by Common Destination
iVi Carrier
Disinterment Date Cemetery Address
E ElReinterment Date Cemetery Address
M ElPermit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury. N Y 12804
Name of Funeral Firm Making Disposition or to Whom •
• Remains are Shipped, If Other than Above
;; Address
I
P' Permission is hereby granted to dispose of the human rtfinscribe in mated.
a
(signature)
District Number 5601 Place C;IPnG Fall N y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
to Date of Disposition 113i la, Place of Disposition ?"4.Vk 1...) Cro-fortu.►
2 (address)
Ui
ta
11 .(section) (lot number) (grave number)
0
AName of Sexton or Person in Charge Premises ���� S�rIN�
2 (please print)
• Signature '�"1 ) Title C2 ol)i-f Ott.
(over)
DOH-1555 (02/2004)